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Registration Form: - Fellow - Junior Fellow - Medical Student Member

This document contains a registration form, curriculum vitae form, and requirements for membership in the International College of Surgeons-Philippine Section. The registration form requests personal and contact information as well as affiliated hospitals and clinics. The curriculum vitae form asks for education history, professional positions, awards, and society memberships. The requirements section outlines the supporting documents needed for three types of membership: Fellow, Junior Fellow, and Medical Student Member. Documents needed include application forms, copies of diplomas, IDs, pictures, and letters of recommendation. Completed applications should be submitted to the ICS Secretariat Office.

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Wahyu Sutrisna
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45 views4 pages

Registration Form: - Fellow - Junior Fellow - Medical Student Member

This document contains a registration form, curriculum vitae form, and requirements for membership in the International College of Surgeons-Philippine Section. The registration form requests personal and contact information as well as affiliated hospitals and clinics. The curriculum vitae form asks for education history, professional positions, awards, and society memberships. The requirements section outlines the supporting documents needed for three types of membership: Fellow, Junior Fellow, and Medical Student Member. Documents needed include application forms, copies of diplomas, IDs, pictures, and letters of recommendation. Completed applications should be submitted to the ICS Secretariat Office.

Uploaded by

Wahyu Sutrisna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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REGISTRATION FORM

SURNAME: _______________________GIVEN NAME: ________________________M.I. ________

SPOUSE NAME: __________________________________________________________________

BIRTHDAY: ____________________PMA # ____________________PRC# __________________

TELEPHONE # __________________CELLPHONE # ________________E-MAIL_______________

HOME ADDRESS: _____________________________________________ZIP CODE :__________

MAILING ADDRESS: __________________________________________ZIP CODE____________

CLINIC ADDRESS: ________________________________________________________________

AFFILIATE HOSPITALS: ___________________________________________________________

-------- Fellow _______________________________


SIGNATURE
------- Junior Fellow

------- Medical Student Member


CURRICULUM VITAE
SURNAME: _______________________GIVEN NAME:________________________M.I. ________

TEL. NO. ___________________CELLPHONE NO. _______________E-MAIL _________________

MEDICAL SCHOOL/S ATTENDED: ___________________________________________________

MEDICAL SCHOOL ADDRESS: ______________________________________________________

DATE OF GRADUATION : ___________________________________________________________

RESIDENCY TRAINING :
Specialty : __________________________________________________________

Training Hospital Attended: _____________________________________________

Years of Training : _____________________________________________________

Important Present Professional Positions and/or Hospital Affiliations :__________________________

________________________________________________________________________________

Important Past Professional Positions and/or Hospital Affiliations : ____________________________

________________________________________________________________________________

Awards/Honors Received : __________________________________________________________

________________________________________________________________________________

Membership in other Professional and Medical Societies: ___________________________________

________________________________________________________________________________

________________________________
SIGNATURE
REQUIREMENTS

FELLOW:
a. Application form (w/ 2 Xerox copies) dully filled and completed
b. Residency Training Certificate of Completion
c. Xerox Copy of M.D Diploma
d. Xerox Copy of P.R.C Diploma
e. Xerox Copy of P.R.C ID
f. Xerox copy of Certificate of Good standing in Philippine Medical Association
through the Component Society
g. Xerox copy of PMA I.D
h. Two (2) 2 x 2 size colored pictures
i. Two (2) endorsement letters from Two (2) fellows of the International College of
Surgeons- Philippine Section

JUNIOR FELLOW:
a. Application form (w/ 2 Xerox copies) dully filled and completed
b. Letter from Training Officer or Chairman of Residency Department, or Medical
Director that you have finished the 1 st Year and that you are still in training in
that Department
c. Xerox Copy of M.D Diploma
d. Xerox Copy of P.R.C Diploma
e. Xerox Copy of P.R.C ID
f. Xerox copy of Certificate of Good standing in Philippine Medical Association
through the Component Society
g. Xerox copy of PMA I.D
h. Two (2) 2 x 2 size colored pictures
i. Two (2) endorsement letters from Two (2) fellows of the International College of
Surgeons- Philippine Section

MEDICAL STUDENT MEMBER:


a. Application form (w/ 2 Xerox copies) dully filled and completed
b. Must be enrolled in an approved school or college of medicine
c. Xerox copy of enrollment registration
d. Xerox copy of school I.D
e. Two (2) 2 x 2 size colored pictures

Please submit the completed ICS Application including all supporting credentials and documents to
the:

ICS SECRETARIAT OFFICE


Room 108 Philippine Medical Association Building,
North Avenue, Brgy. Bagong Pag Asa, Quezon City,
Metro Manila, Philippines
Telefax: +632 928 1190
Mobile #’s: +63 922 354 7407/ +63 916 438 4890/+63 917 839 3942
Email ad: [email protected]
Website: www.ics-ph.com

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